Your feedback is important to us, the information you provide will help us continue to strengthen our Senior Services programs. All responses are confidential, any identifying information you provide will be kept private and utilized for service enhancement.

1. How would you rate your health?*

Excellent

Very Good

Good

Fair

Poor

2. How often are you sick?*

Seldom

Once every six months

Once every three months

Once a month

Once a week

3. How often does your physical and/or emotional health interfere with your ability to attend to personal business, perform simple household chores, or participate in social activities?*